Improving Delivery of Care to Hospitalized Incarcerated Patients

From the 2023 HVPA National Conference

Amelita Woodruff MD (Johns Hopkins Hospital)

While most care for incarcerated individuals is delivered on-site, some of them need to be hospitalized. This brings added expenses, such as secure transportation and guarding. If imprisonment trends continue, cost of providing care for this group can be expected to rise. Educating community hospital providers on practices that can improve the care of this population may help reduce their healthcare costs and safely increase health care value.

The goal of this project was to develop an educational curriculum for hospital clinicians that will improve their ability to identify areas related to treating hospitalized incarcerated patients that can be improved and implement strategies to improve transitions of care to and from correctional facilities when hospitalized in a community hospital.

A literature review was performed using Pubmed. Additionally, meetings were had with stakeholders, including hospitalists, obstetrician-gynecologists, addiction medicine specialists, prison medicine physicians, lawyers and legal/risk management specialists, and private and public correctional medical directors. Data and policies related to hospitalized incarcerated patients were summarized. Notable conclusions were divided into 3 categories – 1) State and federal policies, 2) Clinical care and outcomes; and 3) Successful Interventions. Based on key findings from the above, improvement strategies were proposed and a lecture series was developed to disseminate this information.

State and Federal Policies There are 4 types of correctional health care delivery systems: direct, contracted, state university, and hybrid models. The type influences hospital care and subsequently costs. Many state policies require 24/7 restraints and continuous monitoring of custodial patients by corrections officers.Clinical Care and OutcomesHospitalized incarcerated patients face challenges to worse health outcomes and discharge planningHospital care accounted for about 20% of health spending in 10 states between 2007 and 2011. More recent data revealed that New York was 23% and Virginia 27%.Little data exist on the benefit of shackles; data exist on their harm – injury to patients, impediment of exams, predisposition to falls, deconditioning, and elevated risk of VTE.Interventions California developed an algorithm to identify patients at risk for readmission and required RN follow-up after discharge. Over two years, the hospital readmission rate decreased from 9.3 to 2.4 %.Los Angeles County built an urgent care center at its jail. Subsequently, about five fewer patients a day, were sent to a hospital. After six months, the jail had saved over $1 million in transportation costs and a nearly identical amount from fewer visits.

Incarcerated patients are at risk for poor outcomes, and this is even truer once hospitalized. 3 areas were identified as important themes where improved provider understanding and education could lead to the implementation of interventions that can safely increase healthcare value for this population. Optimized care while in the hospital, such as temporary removal of shackles, initiation of MOUD or infectious disease therapy, and end of life care, including applying for compassionate release, may reduce poor outcomes. Additionally, inpatient stays and costs can be reduced by expanding programs such as telemedicine and mobile services. Replication of established programs in other states to avert some off-site care could be done. A lecture series for hospital providers was developed highlighting the above findings and outlined recommendations on how to implement some of these changes.

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